Health In 2 Point 00

THCB Spotlights: Glen Tullman, Executive Chairman of Livongo

The Luxury to Choose

The 80 year-old woman lay on her mat, her legs powerless, looking up at the small group that had come to visit her. There were no more treatment options left. The oral liquid morphine we had brought in the small plastic bottle had blunted her pain. But, she would be dead in the coming days. The cervical cancer that was slowly taking her life is a notoriously horrible disease if left undetected and untreated and that is exactly what had happened in this case.

We had traveled hours by van along dirt roads to this village with a team of health workers from Hospice Africa Uganda, the country’s authority on end-of-life care, to visit the woman. She was the second patient of a similar condition I would see that afternoon.

Back home, seeing an 80 year-old woman with advanced cervical cancer, let alone two in the same day, was exceedingly rare. In high-income countries, cervical cancer is a largely treatable disease, especially when caught in the early stages. And it is now preventable thanks to a widely accessible vaccine against Human Papillomavirus (HPV), the infectious agent that causes most cervical cancers, called Gardasil, which is recommended for all pre-teens in the United States.

“If only she had had access to Gardasil,” I thought to myself.

Just months earlier I was busy in my private primary care practice in suburban Austin, Texas. In one of the richest countries on the planet that spends more on healthcare per person than anywhere in the world, I was putting forth my best effort to explain to a mother why her 14-year-old daughter, who had never before had any sexual contact, needed the series of 3 shots against HPV. “So this HPV is sexually-transmitted, and she still needs the vaccine even though she is not sexually active? And she does not need this shot to attend school?” Gardasil was a difficult sell in the conservative state that was careful about adopting what government, or anyone for that matter, recommended an individual take on for the sake of public health.

It is now February 2018 and news reports are sounding the alarm about the strain of influenza making its way around the US causing remarkably high rates of hospitalization and death. This disease can be easily prevented by one vaccine each flu season, yet patients decline this vaccine due to any number of excuses. “Won’t I be sick or sore for several days after?” “I am very careful about what I put in my body.” And the online “anti-vax” echo chamber encourages this behavior, turning one anecdote of syncope into several cases of harm attributed directly to a single shot in the arm.

What a luxury to choose from a menu of technological advances to protect one’s health. What a luxury to have an employer or taxpayer fund these ubiquitous means of preventing disease; whether it is a vaccine, a blood test, or a basic treatment. High-income societies have applied the Kantian ethical tenant of autonomy like pros and, sometimes without the rational or even conscious decision-making bit, taken for granted life-saving resources. All to the detriment of their communities. What a luxury.

Considering the Centers for Disease Control and Prevention’s list of the top ten greatest public health feats of the last 100 years, we are on an incredible backslide to the year 1899. Measles was declared eliminated from the United States in 2000 thanks to widespread immunization, yet we now have outbreaks at Disneyland and anticipated future outbreaks due in part to conscientious objectors to the vaccine. Thanks to advancements in water treatment we no longer have major outbreaks of diarrheal disease, yet we now have entrepreneurs selling “raw water.”

What a luxury.

It is a cruel reality of inequality and resource mismatch across the globe when those without resources are clamoring for them and those with resources refuse. Whether based on religious or individuality protests in conservative communities or “natural” ways of life in more liberal communities, the result is the same ignorance of science and reason. What a luxury.

But a heavily and densely populated globe interconnected by the increasing ease of international travel means that one person’s declined influenza vaccine might mean another person’s influenza death. The case of Ebola Virus Disease transported from Liberia to Dallas, Texas in 2014 highlighted how quickly and easily infectious diseases can spread across borders.

When does a society refusing to take advantage of superfluous means present such an egregious affront to the other ethical tenant of justice. In a world of finite resources (yes even in America) when does the conversation about personal responsibility turn to demand that individuals implement what is available to him or her to benefit their global community?

In a decade as a Family Medicine physician in the States I had never before seen a death due to cervical cancer. With our suite of widely used screenings, diagnostic technology, and range of surgical solutions, cervical cancer-related deaths are exceedingly rare. And now that we have deployed the vaccine, Gardasil, cervical cancer rates worldwide have been cut in half.

“If only this woman had had access to Gardasil,” I thought to myself. Instead, the 82-year-old matriarch tried to maintain her dignity in the face of a spreading cervical cancer, urinating on a plastic tarp in her niece’s concrete open-air house and controlling her pain with ibuprofen and oral liquid morphine. If only she had had access to that luxury to prevent her cancer. With a little public will, perhaps her great-granddaughters, and mine, will.

Travis Bias, DO, MPH, DTM&H is a Family Medicine physician in California and medical and public health educator. Connect with him at his blog, The Global Table, or on twitter @Gaujot.

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“It is a cruel reality of inequality and resource mismatch across the globe when those without resources are clamoring for them and those with resources refuse.”

There has always been a concentration of resources by rich counties and a concentration within rich countries, but with the planet’s population at 7.8 billion and going to 11.8 billion by 2100 with global warming resource depletion, there will be a reckoning hell on earth.

I am aware that there is a major measles epidemic that is evolving in Europe just because too many families did just that. Remember that measles is still endemic in various parts of the world, outside of the Americas.

Tough questions, but at least on the vaccines/herd immunity, I am favoring the idea that people should be able to do whatever they want, as long as it doesn’t harm others. So, if people don’t want their kids to get vaccinated, then keep them out of the public, especially the schools.

Travis, You touch on fascinating ethical dilemmas that we rarely discuss: how much do we owe others around us and how much do we owe those who follow us in the future? Is it our moral obligation to get vaccinated so that we contribute to herd immunity?…so that our neighborhood on earth has a high enough percentage of immune folks such that a bug can’t take hold? Is it our duty to always enroll in clinical trials in order to advance the science? Are we being cruel to try to get experimental drugs early before phase III?…cruel to millions in the future who are necessarily waiting for the complete science to be done?

I’m not the one with answers here…..it almost seems an issue outside health care. But I do believe the patients need loyal agents–us doctors–who should try to do our best for our particular patient. Akin to attorney-client loyalty. Aren’t there others who can work on the lofty ethical roles of humans?

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